CQHHS SOPD REFERRAL FORM - CQ Wide
Central Queensland Hospital & Health Service (CQHHS)  
Secure electronic transfer for CQ Referral Centre
Medical Objects: <Send via Medical Objects>
HealthLink EDI: <Send via HealthLink>
Or, fax to the CQ Referral Centre: (1300 017 155)
The above fax number cannot be used for Emergency Department or Mental Health Alcohol and Other Drugs Services
For CQ condition-specific referral criteria, visit CQ_HealthPathways

REFERRAL INFORMATION: 	
RE: <PtFirstName> <PtSurname>			         
DOB: <PtDoB>
Referring GP: <DrName>                                                            
Phone number: <DrPhone>
Reason for service request: <Reason for service request>                             
Referral Date:<Referral Date>
Service provider - Rockhampton: <Service provider - Rockhampton>
Service provider - Gladstone: <Service provider - Gladstone>
Service provider - Emerald: <Service provider - Emerald>
Service provider - Biloela: <Service provider - Biloela>
Service provider - Capricorn Coast: <Service provider - Capricorn Coast>
Service provider - Other: <Service provider - Other (type here if not selected above)>
Priority: <Priority> 
Public Referral: <Public Referral>
Is your practice Telehealth enabled? <Is your practice Telehelath enabled?>
Request for use of telehealth if clinically appropriate? <Request for use of telehealth if clinically appropriate?> 
REFERRAL LETTER: 
<Referral Letter- please detail reason for referral>

Have the CQHHS pathways and criteria been checked?

CONSENTS: 
Does patient consent to referral: <Does patient consent to referral?>
Patient is willing to have surgery if required: <Patient is willing to have surgery (if required)>

CONDITION/ SPECIALITY SPECIFIC CLINICAL INFORMATION- CQ HEALTH PATHWAYS	
HISTORY AND EXAMINATION: - 
Past history list (selected): <SelectedPMH>
Medication list: <SelectedRx>
Investigations relevant to this referral - results <3 months old at time of referral <Ix>

STANDARD CLINICAL INFORMATION 	
Allergies/ adverse reactions: <Reactions> 
Immunisations: <Imm>
Observations: <Observations>
Family History: <FamilyHx>
Social History: <SocialHx>

PATIENT INFORMATION 	
IHI: <PtIHI>
Name: <PtTitle><PtFirstName><PtSurname>
Date of birth: <PtDoB> 
Gender: <PtSex>
Indigenous Status: <PtEthnicity>
Occupation: <PtOccupation>

Patients Contact Details
Residential: <PtAddress>
Postal (if different from above):<PtPOAddress>, <PtPOCity>, <PtPOPostcode>
Home: <PtPhoneH>
Mobile: <PtPhoneMob>
Does patient consent to SMS contact? <Does patient consent to SMS contact?>
Interpreter required: <Interpreter Required>
Preferred Language: <Preferred Language>

Alternative Contact / Carer Details 
Name: <NOKName>
Relationship: <NOKRelation>
Phone: <NOKContact>
Guardian/parent (if different from NOK): <Parent/guardian (if different from NOK)>

Insurance Information: 
Medicare number: <PtMCNo>
Medicare expiry:<PtMCExpiry>
Pension number: <PtPensionNo>
DVA number: <PtDVANo>
Health fund: <PtInsFund>

REFERRING GP's INFORMATION 	
Name: <DrName>
Provider number: <DrProviderNo>
Practice details:<Practice>
Address:<DrAddress>
Phone: <DrPhone>
Fax: <DrFax>
Email: <DrEmail>

I look forward to hearing the outcome of this patient's consultation. 
Yours Sincerely 
<DrName>